Introduction

Mandibular deviation is the deviation of themandible as it moves from a postural position intothe intercuspal position. It may be due to inter-mediate or initial tooth contacts deflecting themandible and it may be associated with a facialasymmetry, which may worsen if the cause of thedeviation is left untreated. Congenital anomalies andenvironmental factors, such as condylar fracture, maylead to the development of facial asymmetry.1,2 Othercauses are believed to be: internal derangements inthe temporomandibular joint,3 rheumatoid arthritis,4osteoarthritis,4–6 condylar hyperplasia or hypoplasia,7,8

temporomandibular ankylosis,9 tumours in the tem-poromandibular region10 and lateral crossbite.11

Untreated fractures of the mandible can display vary-ing degrees of facial asymmetry.2 There have been several long-term studies of children with fracturedmandibular condyles, and the consensus is that manyfractured condyles are undiagnosed and regeneratespontaneously.12–14

Children with a mandibular deviation due to prema-ture tooth contacts should be treated as soon as convenient to avoid the development of a skeletal

asymmetry. Often orthodontic treatment to eliminatethe crossbite is all that is required. We report treat-ment of a child with anterior and unilateral posteriorcrossbites, a mandibular deviation to the left side dur-ing closure of the jaws and a marked facial asymmetry.

Case reportDiagnosisA 13.5 year-old girl with a unilateral posterior cross-bite and noticeable facial asymmetry was referred to aprivate practice office for orthodontic treatment. Herparents gave no history of head injury or significantmedical problems. At the time of examination shehad a full permanent dentition, except for the thirdmolars.

The extra-oral examination revealed that she had anobvious suborbital hypoplasia of the left side of herface (Figure 1). The mandible was displaced to theleft side and the lower dental midline was displaced 6 mm to the left of the facial and upper dental mid-lines. During closure of the jaws into occlusion, initial contacts occurred between the upper right pre-molars and first molar and the opposing teeth. Thebuccal surface of the lower right first molar had wear

© Australian Society of Orthodontists Inc. 2010 Australian Orthodontic Journal Volume 26 No. 2 November 2010 201

Non-surgical treatment of mandibular deviation. A case report

Abdolreza Jamilian* and Rahman Showkatbakhsh†

Department of Orthodontics, School of Dentistry, Islamic Azad University* and Shahid Beheshti University of Medical Sciences,† Tehran, Iran

Background: Mandibular deviation due to premature contact of teeth in crossbite may be associated with facial asymmetry.Aim: To describe the non-surgical treatment of mandibular deviation associated with a marked facial asymmetry.Methods: A 13.5 year-old girl presented with a unilateral posterior crossbite, noticeable facial asymmetry, anterior crossbiteand displacement of the mandible on closure. She had no history of head injury or significant medical problems and her parents rejected surgical correction. A removable appliance was used to correct the crossbite followed by fixed appliances tocomplete treatment.Results: Treatment resulted in a marked improvement in facial symmetry and elimination of the mandibular displacement.Conclusions: Early correction of a functional deviation associated with a unilateral facial asymmetry may avoid the need for surgery.(Aust Orthod J 2010; 26: 201–205)

Received for publication: April 2010Accepted: June 2010

Abdolreza Jamilian: info@jamilian.netRahman Showkatbakhsh: showkatbakhsh@hotmail.com

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facets from contact with the palatal surface of theupper first molar. In the intercuspal position theupper right first and second premolars and the firstmolar were in buccal crossbite and the upper left central incisor, lateral incisor and canine were inpalatal crossbite. On the right side the canine andmolar relationships were Class III, but on the left sidethe molar relationship was Class I and the canine relationship was Class II (Figure 1). There was no evidence suggesting a fractured mandibular condyleand the patient and her parents could not recall anaccident likely to result in a condylar fracture.

The pretreatment radiographs are shown in Figure 2.The posteroanterior cephalometric radiographshowed a conspicuous left side suborbital hypoplasia.The lateral cephalometric radiograph showed a skele-tal Class III relationship and proclined upper andlower incisors (Table I).

Treatment objectives and alternativesThe treatment objectives were to eliminate the ante-rior and posterior crossbites and achieve a normalbuccal occlusion with an ideal overbite and overjet.The treatment plan accepted by the patient and herparents was to extract the upper and lower right second premolars, correct the anterior crossbite witha removable appliance with a posterior bite plane, andthen correct the unilateral posterior crossbite, alignthe teeth and close any residual extraction spaces witha fixed appliance. It was estimated that treatmentwould take 3 years. Alternative treatment plans usingrapid maxillary expansion and miniscrews wererejected. The possibility of future surgery to correctthe skeletal asymmetry was discussed with thepatient’s parents and rejected by them.

Treatment progressThe anterior crossbite was corrected with a removableappliance with a screw behind the upper left incisors

(a) (b) (c)

Figure 1. Pretreatment facial and intra-oral photographs. (a) Frontal view. (b) Frontal view with smile. (c) Intra-oral.

Table I. Cephalometric analysis.

Pretreatment Post-treatment

SNA (degrees) 81.1 78.7SNB (degrees) 79.8 77.6ANB (degrees) 1.3 1.1U1 to MxPl (degrees) 122.0 128.0L1 to MnP1 (degrees) 102.0 101.0Intercisal angle (degrees) 119.0 118.0MMPA (degrees) 11.0 10.0Facial proportion (per cent) 67.0 69.0L1 to A-Pog line (mm) 3.2 2.4SN to MxP1 (degrees) 16.0 15.0

and canine and a posterior bite plane to disoccludethe teeth in crossbite. This appliance was retainedwith Adams’ clasps on the first molars and the firstpremolars and C-clasps on the upper canines andcentral incisors. The patient was instructed to wearthe appliance full-time except for eating, contactsports and toothbrushing. The appliance correctedthe anterior crossbite and was used for 6 months.

A standard 0.018 inch edgewise appliance was thenplaced (American Orthodontics, Sheboygan, WI,USA) and the teeth levelled and aligned with a 0.012inch stainless steel wire and then a 0.016 inch stain-less steel wire. The remaining extraction spaces wereclosed with stainless steel 0.016 inch round archwires.Three intermaxillary elastics were used for 16 monthsto correct the posterior crossbite, mandibular

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(a) (b) (c)

Figure 3. Post-treatment photographs. (a) Frontal view. (b) Frontal view with smile. (c) Intra-oral.

(a) (b) (c)

Figure 2. Pretreatment radiographs. (a) Panoramic radiograph. (b) Posteroanterior radiograph. (c) Lateral cephalometric radiograph.

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deviation and the midlines: one diagonal elastic fromthe upper right canine to the lower left canine; onecross elastic from the buccal surface of the upper rightfirst molar band to the lingual surface of the lowerright first molar band; one cross elastic from the lin-gual surface of the upper left first molar band to the buccal surface of the lower left first molar band.

Following correction of the mandibular midline, aClass III elastic was used to correct the right molarand the canine relationships. After a good occlusalrelationship was obtained, detailing and finishing

procedures were undertaken. The appliance wasremoved after 3 years and 4 months treatment and anupper Hawley retainer placed.

Treatment resultsThe extra-oral photographs show the patient has animproved facial profile and less marked facial asym-metry (Figure 3). The intra-oral photograph showsthat the crossbites have been eliminated, the midlinesare coincident and a normal occlusal relationship hasbeen established. No root resorption was found onthe post-treatment panoramic radiograph (Figure 4).At the end of treatment the upper and lower incisorswere proclined (Figure 5, Table I).

Discussion

When our patient presented we were concernedabout the obvious facial asymmetry and our firstthoughts were that the asymmetry would eventuallyneed surgical correction. The patient and her parentsrejected a surgical solution, which led us to propose amore conservative line of treatment. We set out tocorrect the crossbites and midline discrepancy using aremovable appliance followed by a fixed appliance.The treatment took longer than we anticipatedbecause we asked the patient to remove the removable

(a) (b) (c)

Figure 4. Post-treatment radiographs. (a) Panoramic radiograph. (b) Posteroanterior radiograph. (c) Lateral cephalometric radiograph.

Figure 5. Pre- and post-treatment tracings superimposed on S-N, at sella.

appliance during eating and for some sporting activ-ities, and it may have been left out of the mouth forlonger periods than desirable. Furthermore, becausewe did not use a bite plane with the fixed applianceocclusal interferences slowed correction of the posterior crossbite.

After correction of the anterior crossbite the upperand lower right second premolars were extracted toenable the lower midline to be corrected and to estab-lish Class I canine and molar relationships. At thisstage a full fixed appliance with continuous archwireswas placed and the removable appliance with the biteplane discontinued. On reflection, an upper remov-able appliance with posterior bite planes and fly-overclasps and waxed out over the upper right premolarand molars may have allowed the treatment to pro-ceed more quickly because it would have preventedocclusal interferences from the right premolar andmolar. Further correction and better interdigitationwere achieved by the fixed appliances with the help ofthe diagonal and cross elastics. The mandibular deviation and midlines were corrected and normaloverbite and overjet were achieved. The dental andfacial aesthetics were improved to a great extent.

Facial asymmetry is a difficult deformity to correct.Orthognathic surgery along with orthodontics is thefirst treatment plan for severe mandibular deviation,especially in non-growing patients. It has also beenreported that facial asymmetries in children are frequently due to undiagnosed fractured condylesand that the majority of the condyles regeneratespontaneously.12

Asymmetries can be classified according to the struc-tures involved into dental, skeletal and functional.Dental asymmetries can be due to local factors suchas early loss of deciduous teeth or thumb sucking.Skeletal asymmetries may involve the maxilla,mandible or both bones. Functional asymmetriesarise when a malposed tooth deflects the mandibleduring closure into occlusion or by a constrictedupper arch.2

Conclusion

A patient with mandibular deviation and markedfacial asymmetry was successfully treated non-surgically. Early treatment of crossbites with an assoc-iated facial asymmetry may reduce the facial asymmetry.

Corresponding author

Associate Professor Abdolreza JamilianNo. 2713 Jam Tower Next to Jame JamVali Asr StTehran 1966843133IranTel: 0098 21 2201 1892Fax: 0098 21 2202 2215Email: info@jamilian.net

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